The systolic blood pressure fall should be maintained within 25% of pre-induction or pre-spinal levels and the mean arterial pressure maintained at more than 60mmHg.

 

Rationale

Both spinal and general anaesthesia are associated with falls in blood pressure during hip fracture surgery, general more so than spinal [1].

Hypotension is very prevalent during general and spinal anaesthesia [1].

Lowest recorded intraoperative MAP ~<55mmHg is associated with significantly increased 30d mortality in non-cardiac surgery patients [2-5] and in hip fracture patients [6].

Hypothetically, reducing the prevalence of hypotension may reduce the prevalence of postoperative ‘hypoperfusion’ complications (confusion [7-9], dysrhythmia [5, 10], acute kidney injury [11, 12], poor remobilisation).

Hypotension is an anaesthetic problem that can be prevented or treated by:

  • administering lower dose spinal anaesthesia
  • OR administering age-adjusted doses of general anaesthesia
  • avoiding preoperative dehydration by administering fluid intravenously to all patients at hospital admission
  • pre-induction/pre-spinal administration of 250-500mls crystalloid
  • vasopressors. If the patient is clinically euvolaemic, hypotension is likely to be due to anaesthesia-related vasodilation [13] and/or myocardial depression, and therefore better treated with alpha-agonists and/or beta-agonists respectively, rather than with additional fluids
  • intraoperative administration of more than 1000 (except THR) to 1500 (THR) mls fluid (crystalloid) is seldom necessary.

 

Evidence

1. Royal College of Physicians and the Association of Anaesthetists of Great Britain and Ireland. National Hip Fracture Database. Anaesthesia Sprint Audit of Practice. 2014. http://www.nhfd.co.uk/20/hipfractureR.nsf/welcome?readform (accessed 01/01/2016).

2. Sessler DI, Sigl JC, Kelley SD, et al. Hospital stay and mortality are increased in patients having a “triple low” of low blood pressure, low bispectral index, and low minimum alveolar concentration of volatile anesthesia. Anesthesiology 2012; 116: 1195-203.

3. Willingham MD, Karren E, Shanks AM, O’Connor MF, Jacobsohn E, Kheterpal S, Avidan MS. Concurrence of intraoperative hypotension, low minimum alveolar concentration, and low bispectral index is associated with postoperative death. Anesthesiology 2015; 123: 775-85.

4. Bijker JB, Persoon S, Peelen LM, Moons KG, Kalkman CJ, Kappelle LJ, van Klei WA. Intraoperative hypotension and perioperative ischemic stroke after general surgery: a nested case-control study. Anesthesiology 2012; 116: 658-64.

5. Walsh M, Devereaux PJ, Garg AX, et al. Relationship between intraoperative mean arterial pressure and clinical outcomes after noncardiac surgery: toward an empirical definition of hypotension. Anesthesiology 2013; 119: 507-15.

6. White SM, Moppett IK, Griffiths R et al. Outcomes after anaesthesia for hip fracture surgery. Secondary analysis of prospective observational data from 11 085 patients included in the UK Anaesthesia Sprint Audit of Practice (ASAP 2). Anaesthesia 2016; 71: 506-14.

7. Ballard C, Jones E, Gauge N, et al. Optimised anaesthesia to reduce post operative cognitive decline (POCD) in older patients undergoing elective surgery, a randomised controlled trial. PLoS One 2012; 7: e37410.

8. Radtke FM, Franck M, Lendner J, Krüger S, Wernecke KD, Spies CD. Monitoring depth of anaesthesia in a randomized trial decreases the rate of postoperative delirium but not postoperative cognitive dysfunction. British Journal of Anaesthesia 2013; 110 s1: i98-105.

9. Björkelund KB, Hommel A, Thorngren KG, Gustafson L, Larsson S, Lundberg D. Reducing delirium in elderly patients with hip fracture: a multi-factorial intervention study. Acta Anaesthesiologica Scandinavica 2010; 54: 678-88.

10. Devereaux PJ, Chan MT, Alonso-Coello P, et al. Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery. JAMA 2012; 307: 2295-304.

11. Moppett IK, Rowlands M, Mannings A, Moran CG, Wiles MD, NOTTS Investigators. LiDCO-based fluid management in patients undergoing hip fracture surgery under spinal anaesthesia: a randomized trial and systematic review. British Journal of Anaesthesia 2015; 114: 444-59.

12. Porter C, Moran CG, Moppett IK, Devonald M. The incidence and impact of acute kidney injury in patients presenting with hip fracture. In preparation

13. Nakasuji M, Suh SH, Nomura M, Nakamura M, Imanaka N, Tanaka M, Nakasuji K. Hypotension from spinal anesthesia in patients aged greater than 80 years is due to a decrease in systemic vascular resistance. Journal of Clinical Anesthesia 2012; 24: 201-6.